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“For many years Kristin Thorson and the Fibromyalgia Network have been an invaluable source of information for patients with this condition. Kristin understands the science of fibromyalgia like few others, and in Network writings she is able to make everything from technical scientific findings to everyday practical suggestions understandable to patients."
Daniel J. Clauw, M.D., Director
Chronic Pain and Fatigue Research Center
University of Michigan, Ann Arbor


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Three Medications to Consider

Lidoderm for Pain | Provigil for Fatigue | Mirapex for Sleep

Lidoderm Patch for Pain

Tired of going to your doctor for repeat trigger point injections to relieve your nagging neck, shoulder, and back pain? As an alternative to injections or just putting up with regional pain, ask your doctor about Lidoderm. It's a patch that you place on the sore area and it delivers lidocaine anesthetic into your painful muscles.

Lidoderm patches are available by prescription only. They are formulated to slowly release lidocaine into the tissues over a 12-hour period. The patches have their own gentle surface adhesive (simply peel off the surface wrapping like you do for a band-aide) and each sheet is 4" by 5 ½" in size. They can be cut to any size needed for the job. For example, if your physician routinely injects the muscle junction at the base of your neck (one on each side of your spine), you might cut the patch into fourths and apply two small patches nightly to keep the pain away. If the tension at the base of your neck leads to frequent headaches during the day from tilting your head forward to work, you might apply the patch in the morning before your tension-headaches have a chance to develop. Alternatively, applying the patch to your most troublesome area at bedtime may prevent a particularly sensitive muscle from generating unbearable pain. Of course, if you often experience diffuse low back pain, you may need to use an entire patch everyday—at least during the work week.

Your options with Lidoderm are numerous, but can these patches actually take the place of trigger point injections? And, can they really keep your most nagging pain at bay while you work or sleep? One published case report using Lidoderm patches to treat the regional (myofascial) pain problems of a fibromyalgia patient shows promise.1 Although the indicated use of Lidoderm is for treating the intense regional pain of postherpetic neuralgia, pain specialist Charles Argoff, M.D., of Bethpage, NY, suggests that the use of this patch be broadened "to treat patients with complaints of chronic low back pain, cervical spine pain (neck region), and myofascial pain."2 Backing up his recommendation, he references a small study by Arthur Lipman, Pharm.D., of the University of Utah, which successfully demonstrated that this topical analgesic is effective for myofascial pain.3,4

Studies show that Lidoderm delivers lidocaine only to the tissues beneath the patch and does so without complications that might occur when this anesthetic is administered systemically.5 It works as a sodium channel blocker to inhibit pain transmission in the treated area and doesn't build up in the bloodstream. The only side effect appears to be mild skin irritation for those patients who must use this patch on a continuous basis.6

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Provigil for Fatigue

If you experience excessive daytime sleepiness due to your fibromyalgia or chronic fatigue syndrome, talk to your physician about Provigil (modafinil). It's a stimulant, different from traditional amphetamines, that has been approved for the treatment of narcolepsy and Parkinson's disease.7 One small case report involving four fibromyalgia patients taking 100 mg to 250 mg each morning, two of whom took a 50 mg booster in the afternoon, showed that this drug significantly improved alertness during a three-month trial period.8 A study designed to treat fatigue in multiple sclerosis patients indicates that the drug is well-tolerated.9 The common side effects in healthy controls taking 400 mg each morning were usually mild in nature and often consisted of headache, nausea, nervousness/anxiety, dizziness, and insomnia.10

Narcolepsy is a sleep disorder that causes people to fall asleep uncontrollably. It isn't the same as the sleep disorder and fatigue problems faced by people with fibromyalgia or chronic fatigue syndrome. Low-dose Provigil (50 to 100 mg) may, however, aid your symptoms of fatigue, cognitive impairment, and excessive daytime sleepiness, as well as improve your motivation to exercise.11 Should you consider asking your doctor about this drug? It depends upon the impact that fatigue has on your daily function, and your willingness to take a medicine that could increase preexisting problems of headache and insomnia (the small case report in fibromyalgia involved patients whose jobs were in jeopardy because they could not stay awake). A study comparing caffeine to Provigil (200-400 mg) in healthy controls showed that each agent produced similar benefits in terms of daytime performance and alertness.12 The mechanisms of action for these two drugs differ, but caffeine is by far the cheaper.

If you can't tolerate caffeine and your fatigue level is greatly impeding your function, then low-dose Provigil might be a viable option for you. If Provigil aggravates your sleep, try a lower dose. If that doesn't work, consider taking it on workday mornings only.

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Mirapex for Sleep

Sleep studies indicate that restless legs syndrome (RLS) and periodic limb movements during sleep (PLMS) are common in fibromyalgia patients (roughly 50%). Sinemet (containing an L-Dopa/carbidopa mix) and clonazepam (an anti-seizure benzodiazepine) were identified as treatment options. However, a newer dopa-like drug called Mirapex (pramipexole) is rapidly becoming the most commonly prescribed therapy for RLS/PLMS.13 Mirapex has the least amount of side effects among the dopa-agonist drugs due to its longer duration of action.14 Its main side effects include mild nausea and dizziness. As for clonazepam, it still remains an option for RLS/PLMS, but tolerance buildup requiring a higher dose over time is always a concern.

Sleep expert Harvey Moldofsky, M.D., of The University of Toronto, mentions the use of Mirapex for fibromyalgia patients with RLS and/or PLMS in his recent report on strategies for treating the sleep disorders in fibromyalgia syndrome.15 He says 0.25 mg of Mirapex given at 8:00 p.m. "is very useful in controlling the restless legs and sleep disturbance so that the patient will feel more rested, not fatigued, and alert during the day." Patients may find it easiest to start with the lowest dose of 0.125 mg and work up to 0.25 mg, which is still considered a very low dose.

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Several additional drug and nondrug therapies to consider are discussed on the Treatment page.

1. Dalpaiz AS, Dodds TA. J Pain & Pall Care Pharm 2002; 16(1):99-104.
2. Argoff CE. S Med J 2002; 95(7):781.
3. Argoff CE. Cur Pain Headache Rep 2002; 6(5):375-378.
4. Lipman A, et al. J Pain 2002; 3(2 suppl 1):abs#782.
5. Comer AM, Lamb HA. Drugs 2000; 59(2):245-249.
6. Gammaitoni AR, Davis MW. Ann Pharmacother 2002; 36:236-40.
7. Beusterien KM, et al. SLEEP 1999; 22(6):757-765.
8. Schaller JL, Behar D. J Neuropsych Clin Neurosci 2001; 13(4):530-1.
9. Rammohan KW, et al. J Neurol Neurosurg Psych 2002; 72(2):179-183.
10. Hellriegel ET, et al. J Clin Pharmacology 2002; 42(4):448-458.
11. Jones KD, Clark SR. Rheum Dis Clin N Am 2002; 28(2):419-436.
12. Wesensten NJ, et al. Psychopharmacology 2002; 159(3):238-247.
13. Silber MH. Neurology Clinics 2001; 19(1):173-186.
14. Comella CL. Neurology 2002; 58(4 suppl 1):S87-92.
15. Moldofsky H. Rheum Dis Clin N Am 2002; 28(2):353-365.

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